Multilobular Structure Near the Left Ventricular Apex: Pericardial Effusion or a More Sinister Pathology?

Abstract

A 74-YEAR-OLD, 88 kg, and 178 cm man with known coronary artery disease was referred to the authors’ institution with a progressive shortness of breath when bending forward (bendopnea) and worsening New York Heart Association class III symptoms. The patient previously suffered an anterior-lateral ST-elevation myocardial infarction 7 years before the current admission that had been treated with drug-eluting stents followed by 3-vessel coronary artery bypass graft surgery. A dual-chamber implantable cardioverter-defibrillator was subsequently placed for reduced left ventricular (LV) ejection fraction (10%-20%). He was followed by his cardiologist for a known LV apical aneurysm. The physical examination revealed jugular venous distention, but rales and lower extremity edema were absent. Coronary angiography revealed that the grafts were patent. The cardiac index was normal (2.5 L/min/m2). Transesophageal echocardiography (TEE) was performed as part of the diagnostic evaluation, and the following images were obtained (Figs 1, 2, and 3; Videos 1, 2, and 3). What is the diagnosis?